10 Jul What’s next for General Practice?

With the latest details of the exodus from general practice form the South West region, John Campbell who led the research found that of the 2,000 respondents two in five intended to leave the profession within the next five years. (1) The authors conclude – Healthcare in England faces imminent challenges in respect of GP workforce capacity. The survey identifies the magnitude of the problem in South West England and highlights the important role of GP morale as one important factor contributing to that challenge. Acknowledgement of the magnitude of the problems is urgently required, along with implementation and monitoring of relevant policy and strategy. Failure to do so will risk serious adverse effects on the capacity and ability of the NHS to provide effective primary care to the UK population.

We all know and feel the reasons for the low morale: ever increasing patient expectations and demands, the inability for patients to manage simple illness themselves, longevity and co-morbidities of those patients, swathes of bureaucratic paperwork aimed at deferring responsibility to the General Practitioner (GP), hospital clinic and discharge correspondence and the movement of care from hospitals to the community. The GP has become the final bastion of ownership of patient care, other health professionals providing health interventions, albeit for the benefit of the patient, but no taking no responsibility and passing the care back to the GP when that episode of care has finished.

How do we change this scene of professional dissolution? In 2015 a model was proposed (2) which divided care offered to patients into four quadrants. These were care for patients in acute (reactive) and chronic (proactive) settings, and looked at ambulatory (able to come to the surgery) and non-ambulatory (housebound) groupings.

The model was formulated to devise how to lengthen the routine patient appointment from 10 minutes to 15 or 20 minutes. For this to happen the non-appointed patient contact (urgent unscheduled and home visits) needs to be devolved. This occurs with acute ambulatory care being looked after by groups of practices together, all offering clinicians on a rotational basis at a central location. This model is being used in Gosport (3) where the lack of clinicians led to this new care model. Non-ambulatory patients (home visits) are looked after in an acute home visit setting but this model introduces proactive care, with so called ward-rounds at rest and nursing homes and care to the housebound who live in their own homes. Traditionally the latter do not see clinicians unless they have an acute illness and only the acute problem is dealt with. This model is being used widely and has just been implemented in the New Forest, where West Hampshire CCG has invested over one million pounds in this care model.

These new models allow for GPs to extend their portfolio, without adding to the paperwork burden – other than clear medical notes. It also reduces the incessant demand of their registered list as they are not available at the base surgery.

A GP may choose to drop two sessions in their 50s and work soley for the primary care access centre or as a frailty GP, offering proactive care to housebound patients. The non-ambulatory proactive GP would have time to become acquainted with the patient’s problems and maintain a continuing relationship with that patient and home as the sessions would be regular. The experienced clinicians can also offer mentorship and clinical advice to their professional colleagues working in the other settings.

Younger doctors could build their portfolio clinical career, in reactive and proactive care alongside routine surgery. We need as a profession to start segmentalising care to our patients, as the holistic nature of general practice to date is now broken.

Prof Johnny Lyon-Maris BSc MBBS FRCP MRCGP FAcadMEd FAMEE

Johnny Lyon-Maris has been a part-time GP in the New Forest for 21 years. He is an active GP trainer and is Associate Dean for Southampton, the New Forest and Jersey. He holds an honorary professorship in medical education and faculty development from the University of Winchester and is a visiting research fellow at the University of Southampton. He has a strong interest in the GP workforce and is an examiner on the Induction and Refresher Scheme for England. Through the RCGP he works as an International Development Advisor for Kosovo and has worked in Kuwait, Holland and with Iraqi doctors on faculty development.

References:

Fletcher E, Abel GA, Anderson R, et alQuitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitionersBMJ Open 2017;7:e015853. doi: 10.1136/bmjopen-2017-015853

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1Comment

Interesting idea. Shame to fragment primary care further. One of our key features is continuity of care as people move between these quadrants. I think we can do more to identify people who are doing well for themselves, and do less for them, and spend time building patient capabilities so more people join the cohort of people extending the range of self management.
It is not just about managing demand but building individual and community capabilities. I think primary care as an MDT of a range of skills and roles is well placed to deliver this. We need a business model to support a system that adds real value to health and wellbeing, not just churning through demand.

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